John Stearns is a Senior Managing Director with Ankura’s Washington, DC office and specializes in providing financial, economic, investigative, clinical, operational, and industry expertise assistance to health sciences providers, payers, physicians, and the health law community. John has over 30 years of progressive management experience in acute and post-acute care and is well versed in healthcare reimbursement, fraud and abuse issues, and ancillary operations. In the course of his work experience, he has developed complex financial models and analyzed large volumes of coding, billing, and reimbursement data in a wide variety of industry areas including direct patient care providers, DME suppliers, and other service providers. He has also led independent review organization engagements involving arrangements and large scale medical records sampling and review for patient care providers.
John’s professional experience includes:
Independent Review Organization
- Engagement director for independent review organization engagements according to corporate integrity agreement requirements over the past 15 years for skilled nursing facilities, hospice, acute care hospitals, retail pharmacy, physician third-party billing company, laboratory services, and durable medical equipment (wheelchairs). These engagements required development of sampling and testing protocols that were acceptable to the office of the Inspector General as well as annual reporting of findings. Analyses performed include: unallowable cost reviews; claims testing including billing and coding; arrangements reviews; billing and coding process reviews (systems reviews).
Healthcare Regulatory Compliance Investigations and Reviews
- Engagement director for a wide variety of investigations, disputes, and internal reviews relating to a broad spectrum of healthcare provider service areas. Services include expert testimony, expert reports, self-disclosures, and damages analysis. Example engagements include:
- Defense of several OIG investigations of skilled nursing facility chains related to allegations of aberrant billing practices focusing on high therapy RUG classifications. Analyses included review of government sampling methodologies, review of selected medical records for rebuttal, meetings with government representatives as part of the settlement process, deposition testimony, and preparation of damages analyses.
- Defense of a Department of Justice/ZPIC investigation into a home health agency. The focus of the review was face to face examinations, plans of care, and homebound status.
- Review of GIP level of care claims for a hospice following the OIG self-disclosure protocol, hospice certifications, face to face examinations, and continuing stay documentation. The results were used to support the submission of a multimillion dollar overpayment and to settle litigation.
- Defense of an independent investigation of ambulance services to dialysis patients as part of the defense of a qui tam investigation. The case was dismissed on summary judgment.
- Engagement director for several investigations of payments to several large hospitals (acute care and inpatient rehabilitation hospitals) on outlier payments based on cost to charge ratios as set by the Fiscal Intermediary.
- Review of inpatient rehabilitation claims subject to MAC and RAC audits including the analysis of technical requirements of IRF documentation and medical necessity of admissions.
- Review of billing and coding compliance for orthopedic devices including custom braces, bone growth stimulators, and TENS devices as well as supplies as part of internal audits and government investigations.
- Engagement director for due diligence engagements focusing on regulatory compliance and billing/coding. Target providers include: physician practices (including specialists such as dermatologists, ophthalmologists, dentists, and pain management); hospitalist providers; contract rehabilitation providers; behavioral health/addiction treatment providers; and outpatient physical therapy providers.